Examining the Consequences of Reductions in Opioid Prescribing on Patients, Clinical Care, and Community Health

检查减少阿片类药物处方对患者、临床护理和社区健康的影响

基本信息

批准号：
9287748
负责人：
Kelly Ray Knight
金额：
$ 56.19万
依托单位：
UNIVERSITY OF CALIFORNIA, SAN FRANCISCO
依托单位国家：
美国
项目类别：
财政年份：
2017
资助国家：
美国
起止时间：
2017-05-01 至 2022-02-28
项目状态：
已结题

来源：
https://reporter.nih.gov/project-details/9287748
关键词：
Address Administrator Affect Alcohol or Other Drugs use American American Medical Association Area Caring Centers for Disease Control and Prevention (U.S.)Chronic Clinic Clinical Clinical Nursing Communities Community Health Complex Consult County Crime Criminal Justice Data Diagnosis Disclosure Drug Monitoring Drug Prescriptions Enrollment Environment Ethnography General Population Goals Health Health Personnel Heroin Home environment Human Resources Income Individual Interdisciplinary Study Interview Lead Longitudinal Studies Mediation Medicaid Medical Modeling Monitor Morbidity - disease rate Non-Malignant Opioid Pain Pain management Patient Monitoring Patients Physicians Policies Primary Health Care Public Health Qualitative Methods Qualitative Research Recommendation Recording of previous events Reporting Research Research Personnel Sampling San Francisco Social Impacts Social Problems Societies Source Withdrawal care delivery clinical care community setting disorder prevention end of life experience follow-up improved mortality non-cancer pain opioid misuse pain symptom patient population prescription opioid programs psychologic research study response safety net social

项目摘要

We propose to use qualitative methods to examine the consequences of reductions in opioid prescribing for chronic non-cancer pain (CNCP) on patients, clinical care delivery, and community health. Over 80 million Americans report CNCP, defined as non-malignant pain that lasts longer than three months, not associated with end of life. Escalations in opioid prescribing for CNCP over the past two decades have been associated with dramatic increases in opioid-associated morbidity and mortality. In response, the Centers for Disease Control and Prevention, the American Pain Society, and the American Medical Association developed recommendations to limit reliance on opioids, by encouraging clinicians to (1) consult statewide prescription drug monitoring programs when prescribing opioids; (2) not initiate opioid therapy for CNCP; and (3) monitor, taper, and/or discontinue opioids in CNCP patients. These recommendations are being implemented nationwide and evidence suggests a concomitant decrease in the total number of opioid prescriptions. Yet, little data exist documenting the long term consequences, positive or negative, of reductions in opioid prescribing. The proposed study builds on our previous R01 (DA034625), Pain Management in the Clinic and Community (PMCC), that examined the management of CNCP in patients with a history of substance use who received pain care in safety net clinical settings. Medicaid insured patients with a CNCP diagnosis are more likely than their privately insured counterparts with CNCP to receive opioid prescriptions. Patients with a history of substance use are more likely to receive a diagnosis of CNCP, to be prescribed opioids, and to transition to chronic opioid therapy than patients without substance use histories. The proposed study will use the social-ecological model of health to address the following specific aims: (SA1) To examine the consequences of reductions in opioid prescribing on patients' experiences of CNCP; (SA2) To examine the consequences of reductions in opioid prescribing on patient-clinician relationships and clinical care delivery in primary care safety net settings; (SA3) To examine the consequences of reductions in opioid prescribing from the perspectives of community stakeholders. The proposed longitudinal study will take place in four safety-net clinics and patients' home/community environments in two diverse San Francisco Bay Area Counties. We will conduct qualitative enrollment and follow-up interviews with 30 primary care clinicians and 60 of their CNCP patients with a history of substance use, and clinical observations between clinicians and matched patients (SA1&2). We will theoretically sample 30 of the 60 CNCP patients and conduct ethnography in patients' home environments, and interview 40 community stakeholders (SA1&3). The multidisciplinary research team, consisting of a medical anthropologist, a physician investigator who studies opioid misuse and practices in the safety net, and a nurse/clinical pain policy expert will synthesize the data with the goal of improving our understanding of the consequences of opioid prescription reductions to make clinical and policy recommendations.

我们建议使用定性方法来检查阿片类药物处方减少的后果关于患者，临床护理和社区健康的慢性非癌症疼痛（CNCP）。超过8000万美国人报告CNCP，定义为持续超过三个月的非恶性疼痛，与生命的尽头。在过去的二十年中，CNCP的阿片类药物处方升级与阿片类药物相关的发病率和死亡率的急剧增加。作为回应，疾病控制中心和预防，美国疼痛协会和美国医学协会发展建议通过鼓励临床医生（1）咨询全州处方的建议，以限制阿片类药物的依赖处方阿片类药物时的药物监测计划；（2）不启动CNCP的阿片类药物治疗；（3）监视器， CNCP患者的锥度和/或停止阿片类药物。这些建议正在实施在全国范围内，证据表明阿片类药物处方总数伴随着减少。但是，很少存在数据记录了阿片类药物处方减少的长期后果（正面或负面）。拟议的研究基于我们以前的R01（DA034625），诊所和社区的疼痛管理（PMCC），检查了患有药物使用史的患者CNCP的管理护理安全网临床环境。医疗补助保险人患有CNCP诊断的患者比他们的与CNCP的私人保险对应物接收阿片类药物处方。有物质史的患者使用更有可能接受CNCP的诊断，处方阿片类药物，并过渡到慢性阿片类药物治疗比没有物质使用历史的患者。拟议的研究将使用社会生态模型健康的针对以下特定目的：（SA1）检查阿片类药物减少的后果开处方患者的CNCP经历；（SA2）检查阿片类药物减少的后果在初级保健安全网环境中开处方患者 - 临床医生的关系和临床护理提供；（SA3）从社区的角度检查阿片类药物处方中减少的后果利益相关者。拟议的纵向研究将在四个安全网诊所和患者中进行。两个不同的旧金山湾区县的家庭/社区环境。我们将进行定性对30位初级保健临床医生和60名CNCP患者的入学和后续访谈临床医生和匹配患者之间的药物使用以及临床观察（SA1和2）。我们将从理论上讲，在60名CNCP患者中，有30例，并在患者的家庭环境中进行人种志，以及采访40个社区利益相关者（SA1和3）。由医学组成的多学科研究团队人类学家，一名医师研究人员，研究阿片类药物滥用和在安全网中的实践，护士/临床疼痛政策专家将综合数据，以提高我们对阿片类药物处方减少的后果是提出临床和政策建议。